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Epinephrine for Pediatric OHCA Mirrors PARAMEDIC2

February 19, 2020

Written by Clay Smith

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Epinephrine for out-of-hospital cardiac arrest (OHCA) in children improved return of spontaneous circulation (ROSC) but not 1-month survival or survival with good neurological outcome.

Why does this matter?
PARAMEDIC2 found improved ROSC and 30-day survival with epinephrine during arrest but not 30-day survival with good neurological outcome in adults with OHCA. A recent meta-analysis in adults found improved ROSC and survival to discharge with epinephrine, but not survival with good neurological outcome. What about children with OHCA? Is epinephrine beneficial? (Post amended: PARAMEDIC2 did, in fact, increase 30-day survival.)

ROSC ≠ Survival
This was a nationwide Japanese arrest database with 1.2 million total people but only 3,961 pediatric arrests in children 8-17 years old. In this age range, 88% were >12 years old. Of these, they did propensity matching and identified 304 children who received epinephrine during arrest. These were compared with a matched cohort of 304 children who did not receive epinephrine. For the primary endpoint of 1-month survival, there was no difference; epi 10.2% vs. no epi 7.9%; risk ratio, RR: 1.13 (95%CI 0.67 to 1.93). There was also no difference in survival with favorable neurological outcome; epi 3.6% vs. no epi 2.6%; RR: 1.56 (95% CI 0.61 to 3.96). ROSC was greater in the epi group vs. no epi, 11.2% vs. 3.3%; RR: 3.17 (95% CI: 1.54 to 6.54), respectively. These results are strikingly similar to PARAMEDIC2. An interesting finding was significant improvement in 1-month survival and ROSC as well as nonsignificant improvement in favorable neurological outcome if epinephrine was given <15 minutes vs > 15 minutes. Take care with these results – this was still a retrospective study, with the ever present danger of selection bias and confounding. It also doesn’t address younger children, as the majority of children included were >12 years old. At this point, I still intend to use epinephrine for pediatric arrest. If given, it should be early. (Note: post edited for clarity. Previously, I stated that epi should not be given too early and linked to a study showing the giving epi earlier than 2 minutes in adults with shockable rhythm was associated with harm. Although this is true, this was confusing and I think not helpful for this conversation. That sentence has been deleted. Thanks Dr. Maureen Saint Georges! ~Clay)

Pre-Hospital Administration of Epinephrine in Pediatric Patients With Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol. 2020 Jan 21;75(2):194-204. doi: 10.1016/j.jacc.2019.10.052.

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